I have abdominal pain because of duodenal ulcer. Kindly help.

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Well, it is rarely possible that you have pain secondary to duodenitis and ulcers after taking PPI for so long. Nor did you have H.pylori infection to claim that there is ongoing infection with H.pylori and cause of persistent ulcers.

It is highly likely that you may have excessive functional secretion of the acid (functional dyspepsia) and causing this much pain. I want to know did you have an endoscopy for this? And if yes, when did you have, kindly share the reports if available.

If you suppose to have functional dyspepsia, then the management is a little bit different. This includes some low dose antidepressant medication for a long period of time. These medications are frequently associated with side effects that is why we want to know whether you have been tried with that before and did you develop any side effects from that? Do you have normal bowel movements or diarrhea or constipation? Besides stomach pain do you have abdominal pain around the navel? Any weight loss in the last six months? Do you smoke or take alcohol?

Let me know about all your endoscopy reports (upload them if present) plus answer me the above questions. I may consider giving you some low dose antidepressant medication.

Please be guided that antidepressants are not for depression in your case, I know you do not have. This is just for controlling excessive of chemical which are secreted in the gut causing hypersensitivity of the nerves and pain.

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I understand now and after seeing that fluoroscopic test that you attached (attachment removed to protect patient identity).

You see those barium fluoroscopy tests are not reliable tests to confirm or exclude the presence of duodenitis or duodenal ulcer. The best way to diagnose it is endoscopy. But at the moment, you do not have any alarms symptoms such as significant weight loss i.e. 10% loss of current body weight, or blood vomiting, or vomiting otherwise, therefore endoscopy is not required at the moment.

The milk tends to cause gas and bloating and diarrhea among adults because most of humans at adulthood lose enzyme called lactase which digest the milk but not necessarily cause pain. So my advice is that you should be taking it to moderate level not excessive. Tea or coffee twice made of milk is fine.

Tell me about your bowel habits. Are they normal or loose or constipation?

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Good then. I am thinking to start you on some low dose antidepressant medications. Tablet Escitalopram (antidepressant) 10 mg once daily in the morning, and Alprazolam (antianxiety) 0.5 mg once at night, only for seven days.

The pain seems to be due to functional disorder called epigastric pain syndrome (EPS). Our stomach produces approximately 1 liter of acid juice to help for digestion of food. In some individuals with hypersensitivity of the nerves, this acid causes pain. The reasons why your stomach is hypersensitive is manyfold and often multifactorial. The social, environmental, and behavioral factors are often at interplay in the causation of EPS.

Escitalopram 10 mg will be continued for a certain period of time, for three months at least. Meanwhile, I will reassess your symptoms to adjust the dose.

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Well, the literature says 50+ side effects. However, these side effects are common when started on higher doses such as 20 mg or above. I am starting you on low doses so would not expect much of side effects.

The common side effects which occur secondary to increase blood serotonin are constipation, dry mouth, ejaculation is delayed, increase sleepiness or altered sleep pattern, and pin and needles in the hands. Diarrhea can occur in some, if not constipation.

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Of all the drugs in this class, this is the most safest as reports say. Do not be frightened at all, I will be assessing your symptoms in a week time or even before that, to be sure that you do not develop any side effects. No, the prescription will not be valid there.

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No, I do not think that you endoscopy soon. Well, it is indeed helpful investigation, but chances of finding anything significant in your case are low. That is why I suggested medicine. If I would have found out any alarming symptoms in you, then I would have recommended you earlier.

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I am glad that I have been help to you.

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It is Esomeprazole that can help in the pain.

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Yes, you can double the dose of Pantoprazole or Esomeprazole. You should take either of those. As such no diet restriction. Excessive junk foods is generally be avoided. But taking once a week is fine.

Takeout is fine as far as it is well cooked and contain less spices and oil. Otherwise, I do not want you to abandon takeout, since I know you do not have other options at the moment.

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You are welcome. Keep in touch for further doubts.